The guiding approaches of health assessment refer to specific conventions of when and what type of health assessment to perform. For example, how often should you perform an assessment on the client? What type of assessment should you perform and how comprehensive should it be? Approaches always depend on the context of the situation. As you become more experienced, you will also be able to pick up on cues that require additional assessment.

Health Assessment Frequency

The frequency of a health assessment is determined by the setting (e.g., primary care, long term care, acute care) and the health and clinical status of the client.

• The frequency of a primary care visit depends on the client’s age and their health status and needs. For example, guidelines have been established for the frequency of well-baby and childhood visits and maternal health visits. Also, clients with complex healthcare needs (such as multiple morbidities) will need to see their primary care practitioner more often than a healthy adult.
• The frequency of assessment in a long-term care setting is often determined by concerns voiced by the client, the personal support worker (PSW), or the registered practical nurse (RPN). PSW and RPN typically have more 1:1 contact with clients in long-term care settings and will draw the registered nurse’s attention to concerns that may require further assessment.
• The frequency of assessment in acute care (such as medical or surgical units) will be at least every four hours. In critical care, this frequency is increased to usually every 1–2 hours at least. Clients in critical care are usually on a monitor in which their heart rhythm and vital signs such as oxygen saturation and heart rate are constantly monitored and alarm bells will signal if there is an abnormal change. Although there may be a standard for the frequency of assessment based on the unique population you care for or the institution policy, you must be aware that escalation of care and increased frequency may be needed based on the nurse’s assessment and the client’s clinical status. For example, at times clients may require constant observation (e.g., post-surgery, in critical care environments, a client who is unstable or may show signs of deterioration, or a client in mental health distress with suicide ideation or post-attempt).

Health Assessment Types

There are several ways to describe health assessment types. In this chapter, we refer to four types including: primary survey; focused assessment; head-to-toe (abbreviated version); and complete health assessment. As per Table 5.1, the type of health assessment to be performed is determined based on the context of the situation.

Table 1.5: Types of health assessment

When conducting these assessments, it is important to assess the client’s level of consciousness and level of orientation. New onset disorientation and/or a decrease in level of consciousness are important cues that could indicate clinical deterioration and thus, require immediate intervention. If not yet completed, a primary survey should be done and findings shared with the physician or nurse practitioner.

Level of consciousness is the client’s state of awareness and response to stimuli (voice/sound or physical). Their level of consciousness is described as:

• Alert and oriented: This means that the client is awake (or easily arouses to your voice), engages appropriately in interactions with you, responds appropriately to your questions, and oriented to person, place, time, and self. 
• Confused and disoriented: This means that the client shows altered cognition such as difficulty in memory retention, difficulty following commands, uncertain about the environment around them, inattention, and shows signs of disorientation in terms of person, place, time, and self. They may have delayed or inappropriate/incorrect responses to your questions.
• Lethargic: This means that the client is slow/sluggish to arouse to stimuli. For example, you need to say their name loudly or multiple times or physical shake their arm. They are sleepy, lack energy, slow to respond to your questions, but answers appropriately and are oriented. 
• Obtunded: This means that the client has a significant impairment in their level of consciousness and requires a significant and continuous stimuli (loud voice, vigorous shaking of the arm). They have difficulty to respond because of the impairment, need constant coaxing to respond, can only answer very simple questions with one word responses that are difficult to hear and understand. Without stimuli, they will immediately return to sleep. 
• Unconsciousness: This means that the client does not respond to any stimuli and has no purposeful motor responses.

Level of orientation is assessed by asking the client questions related to:

• Place (questions to ask: Do you know where you are? They may know they are in a hospital because of the room. Thus, you may probe with the question, do you know what hospital you are in?).
• Time (questions to ask: Do you know what date it is? Do you know what day of the week it is? Do you know what month it is? Do you know what year it is?).
• Person (question to ask: Do you know who I am? They may say “yes”, but you should probe with the question, can you tell me who I am? They may be able to identify you as a nurse, but forget your name in some cases).
• Self (question to ask: Do you know who you are? If they respond “yes”, you should probe with the question, can you tell me your name?).

A normal response is that the client is oriented to place, time, person and self. If they are disoriented, you indicate what they are disoriented to. You may indicate oriented to place, person and self, disoriented to time. It is important to consider context when assessing level of orientation. For example, a client may not be aware of the specific date, but knows the day of the week or month.

Activity: Check Your Understanding

References

Considine, J., & Currey, J. (2014). Ensuring a proactive, evidence-based, patient safety approach to patient assessment. Journal of Clinical Nursing, 24, 300-307. https://doi.org/10.1111/jocn.12641

Douglas, C., Booker, C., Fox, R., Windsor, C., Osborne, S., & Gardner, G. (2016). Nursing physical assessment for patient safety in general wards: Reaching consensus in core skills. Journal of Clinical Nursing, 25, 1890-1900. https://doi.org/10.1111/jocn.13201